COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

Home Browse Search

a v STATE OF CALIFORNA t. ` STATE WATER RESOURCES CONTROL BOARD W 4a�, v UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B _ . +'i . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWA( PERMIT . 5 Ct ANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ !:TEMPORARY TANK CLOSURE F--] 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:Chevron Station # 10 �36 I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.a 8. MANUFACTURED BY: C3 C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 0-1000 ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL 8. C. to REGULAR 3 DIESEL 8 AVIATION GAS A• ❑ � UNLEADED ❑ 4 GASAHOL D 2`'PETROLEUM ❑ 60 EMPTY �1 PRODUCT ❑ 1bUNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99OTHER (DESCRIBEAN ITEM 10:BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL; ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER- B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑'`3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LININGA 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION,. ❑ 1 POLYETHYLENE'WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION;; ❑; $ CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) "1 G OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) ..PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFLINDERGROUNO,BOTHIFAPPLICABLE A. SYSTEM TYPE A U i SUCTIONA• 2 PRTSSURE- A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U DOUBLE WALL A U 3 LINED TRENCH A U 95 U!!!!''NKyyyy""""NOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 0FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING 3 IAONRORING ❑99 OTHER V.TANK LEAK DETECTION FEE 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING [:] 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE E] 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION N---O��RMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑7 �71 SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE �f (PRINTED a SIGNATURE) LOCAL AGENCY USI=ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE OUR NUMBERS BELOW COUNTY# JURISDICTIONS FACILITY# TANK# STATE I.D.# m ❑L_1_JT1 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH OCAL AGENCY IMPLEMENTING THE UNDERGROUND ST E TANK REGULATIONS FORM B (12-91) ., FOR003/B-Ai